Knowledge of pelvic floor muscles in community-dwelling women aged over 60: its relationship with urinary incontinence

doi:10.21203/rs.3.rs-4720724/v1

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Knowledge of pelvic floor muscles in community-dwelling women aged over 60: its relationship with urinary incontinence

https://doi.org/10.21203/rs.3.rs-4720724/v1

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Purpose: To investigate the awareness of the pelvic floor muscles (PFMs) and PFM exercises (PFME) knowledge, training and experience in community-dwelling women aged 60 and over and its relationship with urinary incontinence (UI).

Methods: This is a questionnaire based study which was carried out in 9 Physical Medicine and Rehabilitation Centers, including a total of 500 women aged 60 and over and living in the community. The questionnaire included questions about awareness of PFMs, UI complaints and PFME knowledge, training and experience. Knowledge and awareness of PFMs and PFME knowledge, training and experience were compared in subgroups with or without urinary incontinence.

Results: Knowledge and awareness of PFMs and PFME knowledge, training and experience were low in the study population. Knowledge and awareness of PFMs were significantly low in the subgroup with urinary incontinence (p<0.05). Kegel exercise training and experience were significantly low in the subgroup without urinary incontinence (p=0.01, p<0.01).

Conclusion: Knowledge and awareness of PFMs and PFME knowledge, training and experience are low in community-dwelling women aged 60 and over and training programs should be organized to teach the function of the PFMs and to perform PFME correctly in this population.

awareness

female

knowledge

pelvic floor muscles

pelvic floor muscle exercises

urinary incontinence

Aim: The aim of this study was to investigate knowledge and awareness of pelvic floor muscles and pelvic floor exercises in women aged over 60.

Findings: Knowledge and awareness of pelvic floor muscles and exercises are low in women aged over 60. Knowledge and awareness of pelvic floor muscles were significantly low in the subgroup with urinary incontinence.

Message: Clinicians should consider low levels of awareness on pelvic floor muscles in women aged over 60 before implementing pelvic floor exercises for this patient population.

Pelvic floor dysfunction (PFD) manifests itself in various clinical conditions including UI, anal and fecal incontinence, pelvic pain syndrome, sexual dysfunction and defecation problems [1].

PFD occurs when the PFMs are too weak or too tight, or not used properly. Major risk factors associated with PFD are pregnancy, childbirth, obesity, menopause, and chronic obstructive pulmonary disease [2]

In previous studies, it has been suggested that insufficient knowledge and misperceptions about PFD are the biggest barriers to seeking treatment. In a study performed by Neels et al., it was found that there is a significant lack of information about PFMs and PFD in young nulliparous women [3]. In another study, the same authors showed that 75% of peripartum women and 68% of postmenopausal women had insufficient knowledge about PFMs and PFD, or they wanted to have better knowledge [4]. This shows that there is work to be done to better inform all women.

In European Association of Urology Guidelines; all women (including elderly women) with SUI or MUI are recommended intensive PFME for at least 3 months as first-line treatment [5].

PFME are given mostly for the young age group with postpartum UI complaints, and the elderly are neglected in this regard. As far as we know, there is no study in the literature investigating PFM awareness in women over 60 years of age. Before conducting studies to increase the PFM education for this group, it was aimed to investigate the awareness of the PFMs in women aged 60 and over who live in the community about PFMs and its relationship with UI.

This questionnaire based study, which was prepared on the awareness of PFMs and UI complaints of women aged 60 and over living in the community, was carried out in 9 Physical Therapy and Rehabilitation Centers, in a total of 500 patients. This study was approved by the Ethics Committee of Ege University Medical Faculty. All respondents provided written, informed consent before completing the survey. All questions asked to the patients are given in Table-1.

After the demographic information of the patients was recorded, they were asked whether they had UI complaints. In patients with UI; information was obtained about the duration and type of incontinence and whether they had admitted to a physician about this issue.

The patients were questioned in terms of their knowledge of what PFMs do and where they are located. The patients were asked whether they had heard of “Kegel exercises” and, if so, from which source. They were asked if they had ever done Kegel exercises before, if they did; how they trained, how often they did it and, how long they continued.

Patients were also asked about whether they would do Kegel exercises regularly if they were recommended to do them, and how long they should be continued regularly for these exercises to be beneficial.

The answers given to the questions about the pelvic floor muscles and exercises of the respondents were summarized as frequency and percentage. Statistical analyzes were performed in the IBM SPSS Statistics for Windows, Version 25.0 (Released 2017, Armonk, NY: IBM Corp.) package program. All statistical hypothesis checks were performed at the 0.05 significance level.The relationships between urinary incontinence and awareness of pelvic floor muscles and exercises were examined by Fisher’s Exact Test. The number of correct answers to the questions about PFM awareness of women with and without UI were compared by using Pearson Chi-square test.

UI was present in 293 (58.6%) of 500 women aged 60 and over who were living in the community included in this study. Of those 293 women with UI, 95 (%32.4) had stress UI, 97 (%33.1) had urge type UI, and 101 (%34.5) had mixed type UI. The mean age of the women included in the study was 67.79 ± 6.07 (60–88), duration of UI was 47.59 ± 47.45 (min-max: 2-240) months. The mean age of those with and without urinary incontinence was 68.71 ± 6.15 and 66.49 ± 5.72, respectively, and there was no statistically significant difference (p > 0.05). Of those included in the study, 69.6% were married, 27% were divorced or widowed, and 3.4% were single. Regarding the educational status, 52.6% of the participants were primary / secondary school, 16.4% high school, 12.4% university graduate, the others were illiterate.

Eighty-eight women (30% of women with UI) consulted a doctor with complaints of UI, and 64 women (21.8% of women with UI) received any kind of treatment for it.

Twenty-three % of women with UI did not consult a physician because they thought of incontinence as a natural consequence of aging.

134 (26.8%) of all participants stated that they had heard of Kegel exercises before. Forty-three of the 134 participants had heard about Kegel exercises from their physician. Seventy-eight women (15.6%) stated that they had done these exercises before.

It was learned that out of 63 patients who were given Kegel training, this training was given verbally in 43, during the gynecological examination in 12, and in written material in 8 of them.

11 women stated that they did Kegel exercises 2–3 times a week, 7 women everyday. The number of women who continued Kegel exercises for at least 3 months was 35.

When the PFM awareness of women with and without UI was compared, it was determined that the rate of those who had done Kegel exercises before and had received training on this subject was significantly higher in the group with UI (p < 0.01, p = 0.01).

The group with and without UI gave a similar answer to the question “If you were offered Kegel exercises, would you do it?” (52.7% vs, 55.6%) (p > 0.05).

The rate of correct answers to the questiones “What do your pelvic floor muscles do?” and “What are your pelvic floor muscles located around?” increased in parallel with the level of education. Regarding the questiones about the role and place of PFMs, the rate of correct answers was very low in both groups with and without UI, and the rate of correct answers was higher in the group without UI (p < 0.05) (Table-2).

Fante, et al reported a systematic review investigating whether women present adequate knowledge of the main pelvic floor disorders (PFDs) (urinary incontinence – UI, fecal incontinence – FI, and pelvic organ prolapse – POP) [6].

In a randomized controlled study performed by Berzuk et al, pelvic floor knowledge (PFK) and the presence of pelvic floor dysfunction (PFD) symptoms in healthy women working in an office setting were evaluated. While the results of this study can not be generalized to all women, it is obvious that low PFK levels were associated with a high prevalence of PFD. Significant decrease in PFD symptoms and increase in QoL by increasing PFK following a “Pelvic Floor Health and PFME Education” session was detected [7]. It is important that women receive information on the PFM function and dysfunction.

There is a lack of data on the knowledge of adult women regarding to the physiological role of the pelvic floor and the ability to contract the PFMs [6].

In the systematic review performed by Fante et al., UI was the most prevalent PFD investigated [6]. UI is a common condition in the general population, especially in the older adults, which reduces the quality of life and 10–20% of all women and 77% of women living in nursing homes have UI [8].

In the study performed by Kasikci, et al. the prevalence of UI in 1094 Turkish women age 65 and older was found to be 51.6%, and the most common type was urge UI (44.1%).

13.7% with UI reported that they had fallen when getting up from the toilet, 34.3% had experienced a sense of shame, 45.8% avoided coughing, and 46.5% restricted fluid intake [9].

Regarding the PFM exercises recommended for the elderly, we primarily aimed to investigate the awareness of elderly women in our society about PFMs and its relationship with urinary incontinence. Although there are studies about the awareness of PFMs performed in pregnant women, heterogeneous samples of nulliparous women, and peripartum and postmenopausal women, to our knowledge, this is the first investigation about the awareness of PFMs in elderly women living in the community and its relationship with UI.

Hill et al performed a questionnaire based survey evaluating the pregnant women’s levels of awareness, knowledge, and beliefs about the PFMs. Although 76% of respondents knew that PFMs can prevent UI, 41% thought it was normal to leak urine when pregnant, only 11% were practicing PFME [10].

Neels et al performed two studies including heterogeneous samples of nulliparous. It is found that both peripartum women, and postmenopausal women had little knowledge about the pelvic floor [3, 4]. They evaluated the knowledge of young nulliparous women about their pelvic floor. Approximately one third of women thought it was normal to leak urine or need to use a pad for incontinence. Most of the participants (%81) had never received information about the pelvic floor [3]. In the other study, they reported that only half of the peripartum and postmenopausal women ever received information about the pelvic floor and that a majority of them would welcome more information [4].

In the study performed in pregnant women, only 5.4% of the respondents correctly answered and 37.8% stated that they did not know about the question “what do your PFMs go around ?” [10]. While 12.4% of the elderly women in our study answered this question correctly, 75.8% stated that they did not know. Although 76% of the pregnant women correctly identified that PFMs function to prevent UI, only 27% knew that PFMs function to prevent faecal incontinence [1]. These rates reported by the patients in our study were 11.4% and 0.2%, respectively.

Hermansen et al. showed that 76% of women who had UI after delivery were convinced that they had become incontinent due to weakened PFMs and because they did not peform sufficient PFME [11]. Knowledge about PFMs and PFD could positively affect care-seeking behavior. It was recommended that education on PFMs and PFD should be given earlier in life (during school), or before women are exposed to PFD risk factors such as pregnancy and delivery (pre-pregnancy education) [3].

Freitas et al investigated the level of knowledge about the PFMs in Brazilian women age ≥ 18 years, not being pregnant or being more than 12 months postpartum [12]. The participants showed a low level of PFM knowledge. The authors reported that no relationships were found among PFM knowledge, ability to contract the PFMs, PFM strength, and UI. There were statistically significant associations between knowledge and years of education and previous PFM training. The mean PFM knowledge of the participants were extremely low limiting further correlations to be made in groups whose knowledge grouped such as high versus no knowledge. The literature generally shows a positive association between pelvic floor knowledge and higher educational levels [10, 13]. In our study, the rate of correct answers to the questiones which is exploring the knowledge about PFMs “What do your pelvic floor muscles do?” and “What are your pelvic floor muscles located around?” increased in parallel with the level of education (Pearson chi-square test p < 0.001).

In the literature, there is no investigation about the awareness of PFMs in elderly women living in the community. Dunivan et al evaluated UI and pelvic organ prolapse (POP) knowledge among elder Southwestern American Indian women and assessed barriers to care for PFDs. They found that incontinence knowledge is similar to historic gynecology controls. The results showed that almost 50% of the participants believed that the use of pads and diapers and surgery were the only treatment options for UI. The participants reported high levels of barriers to care seeking, especially related to cost and inconvenience [14].

Dumoulin et al performed a randomized clinical trial to determine whether the effectiveness of group-based PFM training is not inferior to individual PFM training in women aged 60 years or older with stress or mixed UI [15]. They reported that the median percentage reduction in incontinence episodes at 1 year was 70% in individual compared with 74% in group-based PFM training intervention. The widespread use of PFM training in clinical practice could increase UI treatment capacity for older women [15]. Many incontinent women feel embarrassed to share UI problems with friends, family, or even health care professions. Also, many women believe that UI is a part of aging and there is no effective treatment other than surgery. In our study 68/293 (%23) patients with incontinence believed that UI is part of aging. For this reason, first of all, training programs should be organized to correct the wrong information on this subject and to teach the patients about function of the PFMs and correctly perform PFME.

Conflict of interest statement:

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Bortolini MA, Drutz HP, Lovatsis D, et al (2010) Vaginal delivery and pelvic floor dysfunction: current evidence and implications for future research. Int Urogynecol J Pelvic Floor Dysfunct 21: 1025–1030.
MacLennan AH, Taylor AW, Wilson DH, et al (2000) The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 107: 1460–1470
Neels H, Wyndaele JJ, Tjalma WA, et al (2016) Knowledge of the pelvic floor in nulliparous women. J Phys Ther Sci 28: 1524–1533
Neels H, Wiebren A A Tjalma , Jean-Jacques Wyndaele et al (2016) Knowledge of the pelvic floor in menopausal women and in peripartum women. J Phys Ther Sci 28: 3020–3029
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Fante JF, Silva TD, Mateus-Vasconcelos ECL, Ferreira CHJ, Brito LGO (2019) Do Women have Adequate Knowledge about Pelvic Floor Dysfunctions? A Systematic Review. Rev Bras Ginecol Obstet Aug;41(8):508-519
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Table-1 : All research questions regarding urinary incontinence, knowlegde of PFMs and PFME knowledge, training and experience in community-dwelling women aged over 60

1-Do you have urinary incontinence?

a-Yes n= 293 (%58.6)

b-No n= 207 (% 41.4)

2-If your answer is yes, which of the following do you have?

a-Urinary incontinence when coughing, sneezing,

laughing n= 95 (%32.4)

b-Urgency urinary incontinence n=97 (%33.1)

c-I have both of them n= 101 (%34.5)

3-How long have you had urinary incontinence (month) - mean±SD (min-max)

47.59±47.45 (2-240)

4-How often do you leak urine?

a-Everyday n=96 (%32,7)

b-Several times a week n= 89 (%30,4)

c-Several times a month n= 87 (%29,7)

d-Several times a year n= 21 (%7.17)

5-Have you ever visited a doctor for urinary incontinence?

a-Yes n= 88 (%30.03 ) (If your answer is “yes”, skip question 7) b-No 205 (%69.97) (If your answer is “no”, continue with question 7)

6-If your answer is yes (n=88); have you received any treatment?

a-Yes n= 64 (%72.73)

b-No n= 24 (%27.27)

7-If your answer is no (n=205), why didn't you go to the doctor?

a-Because I think of incontinence as a natural consequence of aging n= 68 (%33.17)

b-My urinary incontinence is not severe or frequent enough to require treatment n= 92 (%44.87)

c-Cause I'm ashamed to talk about it n= 15 (%7.32)

d-I didn't know there was a cure n= 30 (%14.63)

8-What do your pelvic floor muscles do (n=500)?

a-Prevents urinary incontinence n= 57 (%11.4)

b-Prevents stool incontinence n= 1 (%0.2)

c-Prevents sagging (to be described to patient) n= 22 (%4.4)

d-Prevents all n= 54 (%10.8)

e-I do not know n= 366 (%73.2)

9-What are your pelvic floor muscles located around (n=500)?

a-Urinary bladder outlet n= 37 (%7.4)

b-Vagina n= 19 (%3.8)

c-Rectum outlet n= 3 (%0.6)

d-All of the above n= 62 (%12.4)

e-I do not know n= 379 (%75.8)

10-Have you ever heard of “Kegel exercises” (n=500)?

a-Yes n= 134 (%26.8)

b-No n= 366 (%73.2)

11-If so (n=134), where did you hear it?

a-From my friend n= 23 (%17.16)

b-From my family n= 25 (%18.66)

c-From the newspaper n= 7 (%5.22)

d-From the internet n= 18 (%13.43)

e-From the doctor n= 43 (%8.6)

f-Other resources n= 18 (%32.09)

12-Have you ever done Kegel exercises before (n=500)?

a-Yes n= 78 (%15.6)

b-No n= 422 (%84.4)

(If your answer is no, go directly to question 19)

13-If yes (n=78), have you received training on how to do it?

a-Yes n= 63 (%80.77)

b-No n= 15 (%19.23)

14-If yes (n=63), how did you receive training on Kegel exercises?

a-Verbal description n= 43 (%68.25)

b-With written description n= 8 (%12.69)

c-During the gynecological examination n=12 (%19.04)

15-How often did you do Kegel exercises (n=78)?

a-On occasion (less than once a week) n= 48 (%61.54)

b-1 time per week n= 12 (%15.38)

c-2-3 times a week n= 11 (%14.1)

d-Everyday n= 7 (%8.97)

16-How long did you continue Kegel exercises (n=78)?

a-less than 1 month n= 32 (%41.02)

b-1 month n= 4 (%5.13)

c-2 months n= 7 (%8.97)

d-3 months and above n= 35 (%44.87)

17-If you did Kegel exercises, did your urinary incontinence improve (n=78)?

a-never improved n= 35 (%44.87)

b-partially fixed n= 30 (%38.46)

c-greatly improved n= 5 (%6.41)

d-completely fixed n= 8 (%10.25)

18-Do you still continue Kegel exercises (n=78)?

a-Yes n= 27 (%34.61)

b-No n= 51 (%65.39)

19-If you were offered to do Kegel exercises, would you do it (n=500)?

a-Yes, regularly n= 269 (%53.8)

b-Yes, sporadically n= 65 (%13)

c- No, I wouldn't n= 25 (%5)

d-I do not know n= 141 (%28.2)

20-How long do you think Kegel exercises need to be continued on a regular basis for them to be beneficial (n=500)?

a-1 month n= 25 (%5)

b-2 months n= 6 (%1.2)

c-3 months n= 52 (%10.4)

d-I do not know n= 417 (%83.4)

PFMs: Pelvic floor muscles

PFME: Pelvic floor muscle exercises

Table 2: PFM awareness of women with and without UI

	Women with UI (n=293)	Women without UI (n=207)	P*
What is the role of PFMs?- What do the PFMs do? Number of correct answers (%)	23 (%7.8)	31 (%15)	<0.05
Where are the PFMs located?- Number of correct answers (percentage)	29 (%9.9)	33 (%15.9)	<0.05
Do you know about Kegel exercises? Number of correct answers (percentage)	85 (%29)	48 (%23.2)	>0.05
Have you ever done Kegel exercises? Number of “yes” answers (percentage)	60 (%20.5)	18 (%8.7)	=0.00
Have you received Kegel exercise training? Number of “yes” answers (percentage)	47 (%24.1)	16 (%12.6)	=0.01
If Kegel exercises were recommended, would you do it? Number of “yes” answers (percentage)	154 (%52.7)	114 (%55.6)	>0.05
How long should Kegel exercises be done regularly to be beneficial? Number of correct answers (percentage)	29 (%9.9)	23 (%11.2)	>0.05

PFMs: Pelvic floor muscles, UI: Urinary incontinence

* (Pearson Chi-square test)

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Editorial decision: Major revisions
31 Jul, 2024
Reviewers agreed at journal
21 Jul, 2024
Reviewers invited by journal
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Editor assigned by journal
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You are reading this latest preprint version

Knowledge of pelvic floor muscles in community-dwelling women aged over 60: its relationship with urinary incontinence

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